Paediatric Pearls

Click here for this month’s PDF digest!  It ‘s quite hard providing a balance of information for GPs and ED juniors now that I am only doing the one newsletter.  I think we’ve succeeded this month with neurodevelopmental milestones in Down’s syndrome and essential tremor aimed mainly at GPs and pulled elbow, anaphylaxis and the FEAST study aimed more towards the emergency medicine practitioners.  Many thanks to my colleagues who have contributed this month.  The FEAST video makes fascinating and inspiring watching for any health professional, regardless of specialty.  Do leave comments, questions, suggestions!

Dr Furqan Ahmed is an Emergency Medicine middle grade doctor seconded to paediatrics for a few months as part of his training.  I hope he is learning from us, we are certainly picking up things from him.  He has put together the following guide to “pulled elbow” or “radial head subluxation” for Paediatric Pearls.

Pulled elbow^, Nursemaid’s elbow, is a dislocation of the elbow joint caused by a sudden pull on the extended, pronated arm. The technical term for the injury is radial head subluxation.

Pathophysiology:

The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn.

As children age, the annular ligament strengthens, making the condition less common. The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm.

Causes, incidence, and risk factors

Radial head subluxation is a common pediatric presentation generally occurring between the ages of 1 and 4 years, although it can happen anytime between 6 months of age and 7 years. After age 3, children’s joints and ligaments gradually grow stronger, making radial head subluxation less likely to occur.

The injury occurs when a child is pulled up too hard by the hand or wrist. It is often seen after someone lifts a child up by one arm (eg. when trying to lift the child over a curb or high step).

Other ways this injury may happen include:

• Breaking a fall with the arm
• Rolling over in an unusual way
• Swinging a young child from the arms while playing

Signs and symptoms

When the injury occurs, the child usually begins crying right away and refuses to use the arm because of elbow pain.

• The child may hold the arm slightly bent (flexed at 15-20 degrees) at the elbow and pressed up against the abdominal area (pronated).
• The child will move the shoulder, but not the elbow. Some children stop crying as the first pain goes away, but continue to refuse to move the elbow.
• Tenderness at the head of the radius may be present.
• Erythema, warmth, oedema, or signs of trauma are absent.
• Distal circulation, sensation, and motor activity are normal

Treatment

Inform child and caregiver that the reduction may be uncomfortable, but the discomfort will end quickly after reduction. Parents should not attempt these manoeuvres at home unless advised by a physician.

To resolve the problem, the affected arm must be held with one hand/finger on the radial head and the other grasping the hand making sure the elbow is in 90° of flexion. While applying compression between these two hands, the forearm of the patient is gently supinated and the arm flexed. The manipulator will usually feel a “click” if the manoeuvre is done properly, the child will feel momentary pain, and usually within 5 minutes, the forearm will be functioning well and painlessly.  NB: although a ‘click’ signifies reduction, absence of a ‘click’ is noted in some successful reductions.

Differential diagnoses:

• Fracture, Elbow
• Fracture, Wrist

• Hand Injury, Soft Tissue

Indication for xray:

Child not using arm 30 minutes after a reduction.  External signs of trauma such as swelling, abrasions, or ecchymoses.

Consultations

If radiographic findings demonstrate no fracture, repeat attempts at reduction are unsuccessful, and the child does not regain normal function after 30-40 minutes, the safest management is to support the arm in a sling (or splint and sling) and have the child reevaluated in 1-2 days time.

Prognosis

The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.

For those who have had one occurrence, the chance of recurrence is approximately 20-25%.  Those 24 months and younger may have the greatest risk of recurrence.

References

1. ^ Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW (2012). “Manipulative interventions for reducing pulled elbow in young children”. Cochrane Database Syst Rev (1): CD007759. doi:10.1002/14651858.CD007759.pub3. PMID 22258973. 
2. ^ Toupin P, Osmond MH, Correll R, Plint A (September 2007). “Radial head subluxation: how long do children wait in the emergency department before reduction?”. CJEM 9 (5): 333–7. PMID 17935648. http://www.cjem-online.ca/v9/n5/p333. 
3. ^ Kaplan, RE; Lillis, KA (2002 Jul). “Recurrent nursemaid’s elbow (annular ligament displacement) treatment via telephone.”. Pediatrics 110 (1 Pt 1): 171–4. PMID 12093966. 
4. ^ Macias CG, Bothner J, Wiebe R (July 1998). “A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations”. Pediatrics 102 (1): e10. PMID 9651462. http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=9651462.

…are here!  A bit on TB for your interest, pain scoring tools and links to growth charts.  Also some pointers towards useful e-learning tools.  Do leave comments below.

We currently use 2 recognised pain scores in our Emergency Department, depending on the age of the patient.  The FLACC score (ref) was put together at the end of the 1990′s and has been validated for use in pre-verbal children aged 2 months to 7 years.  The Wong Baker (“smiley faces”) score is for use in the over 3′s.  We also ask older children to give us a mark out of 10 on their pain with 10 being the worst they have ever felt and 1 being not too bad.  Our local pain protocol suggests what the health professional should do with the information gleaned and when the child should be reassessed.  I have reproduced that table for you here.  The UK Department of Health National Service Framework for young people and maternity services says that the prevention, assessment and control of pain in children should be subject to regular audit.

The ED version of May 2011′s “Pearls” is available here!  NICE on otitis media with effusion, inguinal hernias, measles, the child with a limp and the significance of a high anion gap.  Do leave comments below.

May 2011 GP version available here!  Can you tell the difference between septic arthritis and transient synovitis?  We have a new algorithm to help you.  Also a reminder about measles, information on inguinal hernias, NICE on otitis media with effusion and a link to an important discussion on the website about what one can and can not do / take while breastfeeding.  Do leave comments below.

Limping Child Guideline

(with thanks to Dr Rajashree Ravindran)

Children who have hip pathology may present with a variety of non-specific symptoms. They may present with pain, refusal to bear weight, limp, or decreased movement of the lower extremity. If pain is present it is important to determine where it is coming from, as pelvis and low back pathology may refer pain to the hip region and hip pathology commonly presents with referred thigh or knee pain.[1]

The history should include

1. pain characteristics
2. trauma (recent/remote)
3. mechanical symptoms (catching, clicking, snapping, worse during or after activity)
4. systemic symptoms (fever, irritability, weight loss, anorexia)
5. inflammatory symptoms (morning stiffness)
6. neurological symptoms (weakness, altered sensation)
7. gait (limp or not weight bearing)
8. effects of previous treatments (including antibiotics, analgesics, anti-inflammatory drugs, physiotherapy)
9. The current level of function of the child and development

Examination:

1. Temperature and vital signs.
2. Musculoskeletal exam including gait assessment: Look, Feel, Move approach to joint examination can be used. It should be noted that it is exceptionally rare to appreciate swelling of the hip on physical exam as it is a deep joint.
3. A CNS examination is also vital to exclude any neurological pathology.
4. Look for abdominal masses(Neoplasias in children can present with a simple limp)
5. Examine the genitalia(testicular torsion may present simply as a limp[2]) and perform an ENT examination
6. Look for rashes, bruises in unusual areas and remember the possibility of a non accidental injury.

Common differential diagnosis of limp by age:[2] 

Investigations:

Limp due to trauma: If a traumatic fracture is suspected perform an x ray of the affected site and involve the orthopaedic team as appropriate. Always consider the possibility of non accidental injury in a younger child presenting with fracture.

Atraumatic limp: The algorithm as below can be used for guidance.  You may wish to give the parent information leaflet out as part of your “safety netting” as it reminds the family to seek further help if the limp is still present 1 or 2 weeks later.

Algorithm for Child presenting with an atraumatic limp

Parent information leaflet

REFERENCES

1.            Frick, S.L., Evaluation of the child who has hip pain. Orthop Clin North Am, 2006. 37(2): p. 133-40, v.

2.            Perry, D.C. and C. Bruce, Evaluating the child who presents with an acute limp. BMJ, 2010. 341: p. c4250.

3.            Kocher, M.S., D. Zurakowski, and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am, 1999. 81(12): p. 1662-70.

4.            Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.

5.            Howard, A. and M. Wilson, Septic arthritis in children. BMJ, 2010. 341: p. c4407.

6.            Kang, S.N., et al., The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br, 2009. 91(9): p. 1127-33.

7.            Kocher, M.S., et al., Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am, 2004. 86-A(8): p. 1629-35.

8.            Padman, M. and B.W. Scott, (i) Irritable hip and septic arthritis of the hip. 2009. 23(3): p. 153-157.

NICE has recently reviewed its guideline on depression in children and young people – an important diagnosis to be aware of when treating children in the ED.  We have also looked at the evidence around non-sedating antihistamines and found you a “how to do it” video on pulled elbows, and indeed one on umbilical hernia repair in an adult!  Umbilical hernias are common and benign, inguinal hernias may not be.  Read all about it here!